Is Cervical (neck) Fusion Surgery Considered a Radical Solution?

Hi, my name is Dr. John Shim, and I want to discuss anterior cervical discectomy and fusion surgery. At this point, you have already failed non-surgical treatments and have decided to move forward with the operation. When we reviewed your diagnostic studies, the main reason this surgery is offered is secondary to disc herniation, or bone spurs that cause entrapment of the nerves, and cause associated nerve pain, numbness or weakness. Let me show you a typical cervical MRI of a disc herniation. This is a sagittal view. It shows the neck from the side. For most patients, there are some normal disc levels identified, but the offending disc shows a mask pushing backwards onto the spinal canal and nerves or spinal cord. On this axial view, or cross-sectional view, you can see the disc material coming out of the outer layers of the disc, or the annulus, and causing pressure on the thecal sac, the spinal nerves and the spinal cord. For most patients, this will cause radiating pain and numbness in a specific pattern. These numbness and sensation patterns are called dermatomes. There are often associated with reflex and muscle strength findings. For some patients, there is more than one disc level of involvement. Surgery is performed through an incision on the front of the neck. Care is taken to dissect safely through the interval between various muscle groups. Care is taken to protect the windpipe, the food pipe and the arteries and veins. Once the bones of the front of the neck are exposed, the disc herniation is removed from the disc space, taking pressure off the thecal sac, the individual nerves and/or the spinal cord. Compressing bone spurs can also be removed. The bone edges are scraped clear of all soft tissue, and contoured appropriately to accept the bone graft or cage. Once measured, the appropriate size graph is placed in the disk space. Some patients will have more than one disk removed during the operation. Plates and screws are used to secure the bone graft in the disc space, and provide stability while the bone grows into the graph. Once fused, the plates and screws are not necessary, but it is rare to remove the plates and screws unless there is an issue. The incision is closed depending on the circumstance a cervical collar may be recommended. Depending on the circumstance, your surgeon may restrict certain activities for a certain time. The operation has a high success rate, and most patients will be able to return back to the activities after several months. This is the basic animation of the operation. You should discuss your individual concerns with your surgeon this is Dr. John Shim, and I hope this video was helpful for your understanding of the anterior cervical discectomy and fusion operation. Thank you! you

Many people are both upset and frightened when their spine surgeon recommends a fusion as a solution to their neck problems. An anterior cervical discectomy and fusion (ACDF), in the properly selected patient, has a very high success rate, with very satisfied patients.
In our practice, patients who elect to have cervical fusion typically have these following criteria:

  1. Usually, the patients have neck pain with arm radiculopathies (pain, numbness or tingling down the arms and into the hands). Often just on one side in the case of a disc herniation.
  2. Diagnostic studies usually reveal one or more cervical disk herniations, cervical bones spurs (spinal stenosis), or evidence of instability of the cervical spine.  Those are the most common indications for cervical fusions.  Less often, but still common, the studies can reveal a fracture, infection or tumor.  In that scenario, often surgery needs to be performed on an urgent basis.  If you have any of the last three problems, you should have evaluation immediately, so as to avoid a potential permanent problem.
  3. If you have progressive weakness, or increasing pain despite non-surgical care, then you are a candidate.  In some instances, the location of the disk herniation or bone spur may be accessible by a posterior neck decompression surgery called a foraminotomy.  In this situation, you can remove the cause of the neck pain and arm pain without fusion.  Your surgeon will be able to discuss why you would or would not be a candidate for this lesser surgical option.  In general, if the location of the disk herniation or bone spur is more towards the midline of the spine, it can be risky to move the spinal cord to remove the spur with the lesser foraminotomy procedure.
  4. One and two level cervical fusions have a better predicted outcome than three or more levels.  If you need more than two levels, please discuss the rationale for the multiple levels.  In my practice, we try to avoid more than two levels, but, in certain instances such as multiple levels of disk herniations or spurs, you cannot avoid the additional levels of surgery.
  5. Patients are counseled not to smoke.  Any type of fusion surgery has a higher success rate in patients who do not smoke.  Smoking is associated with higher rates of non-union, or failure of the bones to successfully unit.

Cervical fusions are very successful in the properly selected patient, and have a much higher satisfaction and outcome than lower back fusion surgery.  Please do not assume neck fusion surgery and lower back fusion surgery have the same results.  If you have significant neck pain, with corresponding nerve compression pain limited to one or two levels, cervical fusion can be a good treatment option for you.

Citations

  • Gutman G, Rosenzweig DH, Golan JD. The Surgical Treatment of Cervical Radiculopathy: Meta-analysis of Randomized Controlled Trials. Spine (Phila Pa 1976). 2017 Jul 11; PubMed PMID: 28700452
  • Wu TK, Wang BY, Meng Y, Ding C, Yang Y, Lou JG, Liu H. Multilevel cervical disc replacement versus multilevel anterior discectomy and fusion: A meta-analysis. Medicine (Baltimore). 2017 Apr;96(16):e6503. PubMed PMID: 28422837

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